BACKGROUND In patients with or without left bundle branch block, left bundle branch pacing (LBBP) can produce near normalization of QRS duration (QRSd). This has recently emerged as an alternative technique to His bundle pacing.OBJECTIVES The purpose of this study was to characterize a novel approach for LBBP in patients with bradycardia indications for pacing and to assess implant success rate and midterm safety.METHODS Patients with bradycardia indications for pacing underwent LBBP by a trans-ventricular-septal method in the basal ventricular septum. Procedural success, pacing parameters, and complications were assessed at implantation and at 3 months follow-up.RESULTS This prospective study evaluated 87 patients (sinus node dysfunction 67.8%; atrioventricular conduction disease 32.2%) undergoing pacemaker implantation. LBBP implantation succeeded in 80.5% (70/87) of patients and the remaining 17 patients received right ventricular septal pacing. The procedure time of LBBP implantation was 18.0 6 8.8 minutes with a fluoroscopic exposure time of 3.9 6 2.7 minutes. LBBP produced narrower electrocardiographic QRSd than did right ventricular septal pacing (113.2 6 9.9 ms vs 144.4 6 12.8 ms; P , .001). There were no major implantationrelated complications. The pacing threshold was low (0.76 6 0.22 V at implantation and 0.71 6 0.23 V at 3 months), with no loss of capture or lead dislodgment observed.CONCLUSION This study demonstrates that in patients with standard bradycardia pacing indications, LBBP results in QRSd , 120 ms in most patients and can be performed successfully and safely in the majority of patients.

Aims The present study was to evaluate the feasibility and clinical outcomes of left bundle branch area pacing (LBBAP) in cardiac resynchronization therapy (CRT)-indicated patients. Methods and results LBBAP was performed via transventricular septal approach in 25 patients as a rescue strategy in 5 patients with failed left ventricular (LV) lead placement and as a primary strategy in the remaining 20 patients. Pacing parameters, procedural characteristics, electrocardiographic, and echocardiographic data were assessed at implantation and follow-up. Of 25 enrolled CRT-indicated patients, 14 had left bundle branch block (LBBB, 56.0%), 3 right bundle branch block (RBBB, 12.0%), 4 intraventricular conduction delay (IVCD, 16.0%), and 4 ventricular pacing dependence (16.0%). The QRS duration (QRSd) was significantly shortened by LBBAP (intrinsic 163.6 ± 29.4 ms vs. LBBAP 123.0 ± 10.8 ms, P < 0.001). During the mean follow-up of 9.1 months, New York Heart Association functional class was improved to 1.4 ± 0.6 from baseline 2.6 ± 0.6 (P < 0.001), left ventricular ejection fraction (LVEF) increased to 46.9 ± 10.2% from baseline 35.2 ± 7.0% (P < 0.001), and LV end-diastolic dimensions (LVEDD) decreased to 56.8 ± 9.7 mm from baseline 64.1 ± 9.9 mm (P < 0.001). There was a significant improvement (34.1 ± 7.4% vs. 50.0 ± 12.2%, P < 0.001) in LVEF in patients with LBBB. Conclusion The present study demonstrates the clinical feasibility of LBBAP in CRT-indicated patients. Left bundle branch area pacing generated narrow QRSd and led to reversal remodelling of LV with improvement in cardiac function. LBBAP may be an alternative to CRT in patients with failure of LV lead placement and a first-line option in selected patients such as those with LBBB and heart failure.

Background - Left bundle branch pacing (LBBP) is a technique for conduction system pacing, but it often results in right bundle branch block (RBBB) morphology on the electrocardiogram. This study was designed to assess simultaneous pacing of the left and right bundle branch areas to achieve more synchronous ventricular activation. Methods - In symptomatic bradycardia patients, the distal electrode of a bipolar pacing lead was placed at the left bundle branch area via a trans-ventricular septal approach. This was used to pace the left bundle branch area, while the ring electrode was used to pace the right bundle branch area. Bilateral bundle branch area pacing (BBBP) was achieved by stimulating the cathode and anode in various pacing configurations. QRS duration, delayed right ventricular activation time (dRVAT), left ventricular activation time (LVAT) and inter-ventricular conduction delay were measured. Pacing stability and short-term safety were assessed at three-month follow-up. Results - BBBP was successfully performed in 22 of 36 patients. Compared with LBBP, BBBP resulted in greater shortening of QRS duration (109.3±7.1 ms vs. 118.4±5.7 ms, P<0.001). LBBP resulted in a paced RBBB configuration, with a dRVAT of 115.0±7.5 ms and inter-ventricular conduction delay of 34.0±8.8 ms. BBBP fully resolved the RBBB morphology in 18 patients. In the remaining 4 patients, BBBP partially corrected the RBBB with dRVAT decreasing from 120.5±4.7 ms during LBBP to 106.1±4.2 ms during BBBP (P=0.005). Conclusions - LBBP results in a relatively narrow QRS complex, but with an inter-ventricular activation delay. BBBP can diminish the delayed right ventricular activation, producing more physiological ventricular activation.

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